Why It’s O.K. for Doctors to Participate in Executions

On Thursday, Arkansas executed a 51-year-old convicted murderer named Ledell Lee, the first of four prisoners the state intends to execute by the end of the month. That would set a pace rarely if ever matched in the modern history of American capital punishment. The state’s rationale for its intended spree is morbidly pragmatic: The stock of one of its three execution drugs, the sedative midazolam, will expire at the end of April.

The three drugs in Arkansas’s execution protocol — midazolam; vecuronium bromide, a paralytic used during surgery that halts breathing; and potassium chloride, which stops the heart — are administered intravenously. The execution procedure therefore requires the insertion of catheters, controlled injection of lethal drugs and monitoring of a prisoner’s vital signs to confirm death. This makes it important that a doctor be present to assist in some capacity with the killing.

The American Medical Association, however, strongly opposes physician participation in executions on ethical grounds. Selecting injection sites, starting intravenous lines and supervising administration of lethal drugs, the association says, violate a doctor’s oath to heal or at least to do no harm. Doctors who defy the association’s guidelines face censure and the threat that a state medical board might revoke their license, though it is doubtful such punishment has ever been carried out.

I disagree with this view. Though I oppose capital punishment as a matter of principle, as a doctor I believe physician presence at executions is consistent with our mandate to alleviate suffering.

Of the 31 states that allow the death penalty, many require physician participation. The A.M.A.’s position, supported by the American Society of Anesthesiologists and other societies, puts the medical and penal systems in this country at odds.

The A.M.A.’s position is principled and respects a long history of bioethics in this country. However, it is not practical. States that do not require physician presence typically use other medical professionals, such as emergency medical technicians or paramedics, to insert IV lines and possibly mix the drugs. Barring doctors from executions will only increase the risk that prisoners will unduly suffer.

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A protest in Little Rock, Ark., against the death penalty. Arkansas plans to execute four prisoners in April.CreditTamir Kalifa for The New York Times

A lot can go wrong during lethal injections. In 2014 in Oklahoma, to cite just one gruesome example, a 38-year-old convicted murderer named Clayton Lockett writhed in pain at his execution, clenching his teeth and straining to lift his head off the pillow, according to witnesses, after a botched injection into a vein in his groin.

A standard three-drug protocol for executions — sodium thiopental, pancuronium bromide and potassium chloride — was developed in Oklahoma in 1977 but has since been altered in many states, including Arkansas. Florida today uses midazolam instead of thiopental. Other states use pentobarbital, or a morphine derivative along with midazolam. Some states have adopted two-drug and even single-drug protocols — in the absence of scientific study. For all the drugs used, execution is an “off-label” use.

Obviously, no scientific review board would allow the testing of novel execution procedures on human subjects. So, in the absence of controlled investigation, perhaps the best protection against a botched execution is to have a doctor trained in anesthesia or palliative care be present when things go awry.

Physician participation does not guarantee an execution won’t be bungled (a doctor administered the injection at Mr. Lockett’s execution), and I know of no studies of its efficacy (physician participation has been largely shrouded in secrecy because of the stigma attached). But it is hard to believe there would be more chance of a botched injection or inadequate anesthesia if medically qualified personnel were present.

Discouraging physician participation, as the American Medical Association does, will not lead to a ban on capital punishment or lethal injection. If anything, it will lead only to the reinstatement of more brutal forms of execution that do not require medical expertise, such as electrocution or death by firing squad. A few states have already decided to use these methods as possible alternatives.

Doctors have a duty to alleviate suffering. No one would object to a doctor’s providing comfort — spiritual or narcotic — to a terminally ill patient at the hour of death. It is not a stretch to think of death-row inmates who have exhausted their appeals as having a terminal disease with 100 percent mortality.

I recognize the moral quandary that the situation presents for doctors whose hope is that killing by the state will end. But as Arkansas has shown, states will go to great lengths to execute criminals, even at the risk of causing undue suffering.

Doctors can act as a safeguard against this brutality. Participating in executions does not make the doctor the executioner, just as providing comfort care to a terminally ill patient does not make the doctor the bearer of the disease.

Sandeep Jauhar is a cardiologist and a contributing opinion writer. He is at work on a cultural, personal and scientific history of the human heart.